Trump Declares Opioid Emergency. The Opioid Crisis a National Public Health Emergency

More than 300,000 Americans have died from overdoses involving opioids since 2000. President Donald J. Trump has mobilized his entire Administration to address opioid abuse by directing the declaration of a nationwide Public Health Emergency.

President Trump announced that his Administration was declaring the opioid crisis a national Public Health Emergency under federal law, effective immediately. “I am directing all executive agencies to use every appropriate emergency authority to fight the opioid crisis,” the President said.

Trump declared an emergency over opioids

On March 19, 2018, President Trump unveiled a new website, CrisisNextDoor.gov, where Americans can share their own stories about the dangers of opioid addiction. “This epidemic can affect anyone, and that’s why we want to educate everyone,” the President said at Manchester Community College in New Hampshire.

Working off of the recent recommendations in the interim report issued by the President’s Commission on Combating Drug Addiction and the Opioid Crisis, President Donald Trump has issued a directive to his administration to use all “appropriate emergency and other authorities to respond to the crisis caused by the opioid epidemic.”

Some of the immediate actions the Trump administration could take to address the opioid crisis include: (1) approve state waivers to remove the Medicaid Institutions for Mental Diseases (IMD) exclusion, which prohibits the use of federal Medicaid funds for care provided to most patients in mental health and substance use disorder residential treatment facilities larger than 16 beds; (2) negotiate lower prices for naloxone (the drug that reverses opioid overdoses) as suggested by the Commission; and (3) distributing some of the $45 million in the Public Health Emergency Fund. Earlier this week, President Trump suggested the administration would combat the epidemic by focusing on law enforcement and security on the southern border to stop illegal drugs from entering the country.

To much fanfare last year, President Donald Trump ordered his administration to declare a public health emergency over the opioid epidemic. “As Americans, we cannot allow this to continue,” Trump said at the time. “It is time to liberate our communities from this scourge of drug addiction.”

Trump Declares Opioid Emergency
Trump Declares Opioid Emergency

A new report from the Government Accountability Office (GAO) looked at the results of that emergency declaration. The report found little came out of the declaration.

According to the GAO audit obtained exclusively by Vox, the declaration enabled the Trump administration to make use of three new authorities — clearing paperwork requirements for a survey of health care providers about addiction treatment, allowing two states to move forward faster with programs to address the opioid crisis, and expediting support for research about opioid addiction and overdoses.

None of this is bad, but it’s certainly not groundbreaking — particularly for an overdose crisis that’s broken records for overdose deaths year over year, reaching an estimated 72,000 drug overdose deaths in 2017.

Sens. Patty Murray (D-WA) and Elizabeth Warren (D-MA), who along with other Democrats requested the GAO audit, criticized the Trump administration for what they see as inaction.

“Communities are desperately in need of more help to address the opioid epidemic. President Trump, as this report shows, has broken his promises to do his part,” Warren said in a statement. “I’ve asked this administration time and time again to show what actions they are taking to meaningfully address this crisis. No response. To me, it looks like empty words and broken promises. Hand-waving about faster paperwork and speeding up a few grants is not enough — the Trump Administration needs to do far more to stop the opioid epidemic.”

The White House did not respond to a request for comment prior to publication.

The Trump administration told the GAO that it is doing what it can with the emergency authorities unlocked by the declaration. The administration has also pointed to other steps it has taken in response to the opioid crisis. This year, for example, Congress, with Trump’s support, enacted more funding for addiction treatment as part of the federal budget.

But Trump’s emergency declaration is emblematic of the federal response to the opioid crisis so far: Despite a lot of promises and self-congratulating by the federal government on what it’s done, experts say that the White House and Congress need to go much further than they have so far — particularly when it comes to new dollars for addiction treatment.

Trump’s limited emergency declaration over the opioid crisis
The public health emergency declaration came upon the request of an opioid commission set up by Trump. As part of its preliminary report, the commission asked the administration to declare an emergency to remove regulatory barriers and unlock more resources to try to open up access to addiction treatment.

Trump followed through with the request in October 2017, with his typical flair.

But experts warned from the start that the impact of such a declaration would be fairly limited. They said it could mostly get some programs and research out faster. And it could unlock some funding — although, as the GAO noted, the Public Health Emergency Fund only has about $57,000 in it, and the Trump administration has not requested more funding for it.

As I wrote at the time, it was a limited move, but it would help jump-start some action in the opioid epidemic.

That seems to be what happened. A survey asking doctors about buprenorphine, a highly effective addiction treatment for opioid use disorder, got out faster — which will help shape federal policy regarding buprenorphine and addiction treatment in the future. Two states’ programs managed to skip some regulatory hurdles. Research was expedited.

But in total, the Trump administration has only used three of 17 authorities that the GAO found in connection to the emergency declaration. The Trump administration argued that many of these other authorities aren’t relevant to the opioid crisis; given that these kinds of authorities were traditionally formed to deal with more conventional public health crises (like, say, an Ebola or flu outbreak or natural disaster), they just aren’t fit to deal with a drug overdose epidemic.

For example, the declaration allowed the use of National Dislocated Worker Grants to “provide funding to create temporary employment opportunities to assist with clean-up and recovery efforts, among other things,” the GAO reported. But administration officials pointed out that “another grant option is available — the National Health Emergency Dislocated Worker Demonstration Grants — which was established to help communities address the economic and workforce-related impacts of the opioid crisis.” So the National Dislocated Worker Grants may be unnecessary, and, as a result, no eligible entities have applied for them.

There are some emergency authorities that Murray and Warren’s offices argue the Trump administration could be making a greater use of, such as in telemedicine. Advocates have pushed for relaxing rules around telemedicine so it can be done more easily for addiction treatment. But the Trump administration refused to use available emergency authorities to ease access to telemedicine, telling the GAO that “federal law provides for other circumstances under which these restrictions do not apply, thereby allowing the use of telemedicine” — as if the action taken so far by the administration on this issue was enough.

The reality, though, is a public health emergency declaration was never going to be enough to, as Trump suggested, “liberate our communities from this scourge of drug addiction.” It was always far too limited.

But this is a problem you consistently see with Trump and the opioid crisis. You could imagine a world where he declares an emergency, acknowledges the limits, and calls for specific further steps that could be taken — maybe some of the dozens of other proposals put forward by his opioid commission. Instead, we got a flashy press conference with bold but vague promises. It’s a Trump-y preference for presentation instead of substance.

The failings of the emergency declaration are representative of the federal response to the opioid crisis in general: well-intentioned, even good, ideas that are ultimately not enough.

The federal government needs to do more on the opioid crisis
It’s not that the Trump administration or Congress have done nothing in the face of the opioid epidemic. Beyond the public health emergency, the Trump administration has taken some regulatory steps — such as pulling back restrictions on Medicaid funding for addiction treatment — that will help expedite state policy responses.

Congress also recently passed and Trump is soon expected to sign the Support for Patients and Communities Act, which takes largely regulatory steps to expand access to addiction treatment and research regarding opioid addiction and pain. And Congress has allocated funding for the opioid crisis, including $500 million a year in the Cures Act (which has so far been renewed) and $3.3 billion in the fiscal year 2018 budget.

When I’ve asked experts about these approaches, it’s not that any of them are bad. It’s that they fall short. For instance, Leana Wen, the former health commissioner of Baltimore (and soon-to-be president of Planned Parenthood), said that the Support for Patients and Communities Act “is simply tinkering around the edges.”

The funding numbers are one such example. While Congress’s extra billion dollars here and there are good, experts estimate that potentially tens of billions more are needed each year. (For reference, a 2016 study put the total economic burden of prescription opioid overdose, misuse, and addiction at $78.5 billion in 2013.)

That much money is necessary in large part because the state of addiction treatment in America is abysmal. Federal data suggests that only one in 10 people with any substance use disorder and one in five people with an opioid use disorder seek specialty treatment.

Even when an addiction treatment clinic is available, fewer than half of facilities offer opioid addiction medications like methadone and buprenorphine — which are considered the gold standard of care — as an option. Treatment is inaccessible enough that most people who need it don’t get it, and even when treatment is available, it doesn’t meet the best standards of care.

So experts say something more systemic and encompassing, like Vermont’s hub and spoke system or Virginia’s Medicaid reforms, are needed in this area.

Trump, of course, could push for a bolder approach that attempts to get more resources and bigger reforms, or at least try to get his fellow Republicans to make a push in Congress.

But in talking to people involved with the legislation so far, they’ve told me that it’s Democrats who have consistently asked for more — including more significant funding for the crisis — and Republicans who have resisted, citing concerns about the role and size of government and general reluctance toward more spending.

To this end, Warren proposed the Care Act with Rep. Elijah Cummings (D-MD), which would increase federal spending to address the opioid crisis by $100 billion over 10 years. The bill, however, hasn’t budged in the Republican-controlled House or Senate.

As Keith Humphreys, a drug policy expert at Stanford who helped with the Support for Patients and Communities Act, told me, “This reflects a fundamental disagreement between the parties over whether the government should appropriate the large sums a massive response would require. Lacking that, Congress did the next best thing — which is to find agreement on as many second-tier issues as they could.”

The end result is similar to the emergency declaration: There are some genuinely positive steps, but in terms of addressing an overdose crisis killing tens of thousands of Americans each year, it’s simply not enough.

The emergency declaration may allow the government to deploy the U.S. Public Health Service, a uniformed service of physicians and other staffers that can target places with little medical care or drug treatment, said Andrew Kolodny, co-director of opioid policy research at the Heller School for Social Policy and Management at Brandeis University. He said the DEA might be able to use the emergency to require prescriber education for doctors and others who dispense opioids.

This comes after several states (Arizona, Florida, Maryland and Virginia) have already declared emergencies. And in recent months, the Centers for Disease Control and Prevention, the Food and Drug Administration, Congress, physician groups and the insurance industry have taken institutional steps to address the crisis. At the street level, police, firefighters and paramedics now routinely carry naloxone.

ONE YEAR AFTER TRUMP DECLARED OPIOID ADDICTION A PUBLIC-HEALTH EMERGENCY, WHAT'S CHANGED?

A year ago Friday, President Donald Trump directed his government to designate the "opioid crisis" a national public-health emergency. Nearly 64,000 Americans had died of drug overdoses in the previous year—most of them after taking synthetic opioids such as fentanyl—amounting to a rate that was three times higher than the overdose death rate in 1999.

Now, a year later, what has the emergency declaration accomplished? Not much, outside experts say.

Declaring a public-health emergency legally opens up certain powers for the government to move more quickly, and with less oversight, to respond to important health problems. Since Trump's first announcement, the Department of Health and Human Services has renewed the national opioid emergency four times, most recently on October 18th. In this past year, officials have used the declaration to run and expedite studies of the problem, and to help two states launch anti-addiction programs faster than usual, according to a new report from the Government Accountability Office, which conducts investigations for Congress.

Officials could have done much more with the declaration, experts say. "I think what the report highlighted was the lack of leveraging [of] these powers under the opioid public-health emergency," says Rebecca Haffajee, a professor who specializes in health law at the University of Michigan.

"I don't think it's doing anything," says Keith Humphreys, a psychiatrist who studies addiction policy at Stanford University. He was also an adviser to the Obama White House's anti-addiction efforts.

When asked whether the declaration has helped Ohio, which had the nation's second-highest opioid overdose rate in 2016, Eric Wandersleben, a spokesman for the Department of Mental Health and Addiction Services there, replied with an email that addressed major federal funding programs, but not the emergency declaration, which didn't give states any money. When pressed, Wandersleben wrote that "the federal emergency declaration did not directly impact our approach in Ohio."

The Department of Health and Human Services didn't respond to a request for comment.

Officials' descriptions of what they did with the emergency declaration don't suggest Ohio, or the vast majority of states, saw big results from it. Officials used the declaration to take three main actions, according to the Government Accountability Office, which interviewed Department of Health and Human Services officials and other federal leaders for its report. The federal health department surveyed 13,000 doctors and nurses about whether they prescribed burprenorphine, a crucial medicine for treating opioid addiction. The emergency state let officials send out the survey without White House approval, speeding up the process. The department approved two Medicaid programs, in New Hampshire and Louisiana, aimed at treating opioid addiction. Again, the emergency declaration let officials move faster than usual, this time by skipping the two-and-a-half-month public comment and waiting period such projects normally require. Finally, officials expedited National Institutes of Health funding for research on opioid addiction.

Trump's health department has routinely touted its "five-point" strategy to combat the opioid crisis: prevention, treatment and recovery; expanding access to the overdose reversal drug naloxone; improving data about the scope of the crisis; and supporting research on pain and how it is managed.

Nevertheless, Eric Hargan, the acting HHS secretary, said in November that the president was leaving it to Congress to decide whether more money should be appropriated. Democrats argued hypocrisy.

The administration has also proposed loosening privacy restrictions so it’s easier to notify a family about a loved one’s overdose, and CDC launched a new media campaign on the risks of addiction. Many of these initiatives, too, began before the emergency declaration.

“We have yet to see the president take the serious actions this emergency demands and that he promised on the campaign trail,” Sen. Patty Murray (D-Wash.) said during a Health, Education, Labor and Pensions Committee hearing Tuesday on the opioid crisis. “Our communities are crying out for serious solutions, not stunts.”

Although congressional appropriators have not committed to new funding, two health committees have held hearings and are in the early stages of considering major legislation this year. HELP Chairman Lamar Alexander (R-Tenn.) has said that he expects Congress to appropriate new money but would not predict when or how much.

“It’s surprising, given all the talk and the splash, that neither Congress nor the administration has really given this the energy it needs,” said Michael Fraser, executive director of the Association of State and Territorial Health Officials. “It’s disappointing.”

References:

[1] The Opioid Crisis | The White House https://www.whitehouse.gov/opioids/

[2] President Donald J. Trump’s Initiative to Stop Opioid Abuse and Reduce Drug Supply and Demand https://www.whitehouse.gov/briefings-statements/president-donald-j-trumps-initiative-stop-opioid-abuse-reduce-drug-supply-demand-2/

[3] President Donald J. Trump Is Taking Action to Stop Youth Opioid Abuse https://www.whitehouse.gov/briefings-statements/president-donald-j-trump-taking-action-stop-youth-opioid-abuse/

[4] Opioid Package Passes Congress, to be Signed by President Trump https://www.grassley.senate.gov/news/news-releases/opioid-package-passes-congress-be-signed-president-trump

[5] Smith's Legislation to Fight Opioid Epidemic Signed into Law by President Trump https://jasonsmith.house.gov/newsroom/documentsingle.aspx?DocumentID=962

[6] HHS Awards Over $1 Billion to Combat the Opioid Crisis https://www.hhs.gov/about/news/2018/09/19/hhs-awards-over-1-billion-combat-opioid-crisis.html

[7] Trump Administration Taskforce Completes Successful Opioid Bust in Arizona https://www.doi.gov/pressreleases/trump-administration-taskforce-completes-successful-opioid-bust-arizona